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Pediatrics
April 2011, VOLUME 127 / ISSUE 4
From the American Academy of Pediatrics
Article

The Medical Home: Health Care Access and Impact for Children and Youth in the United States

Bonnie B. Strickland, Jessica R. Jones, Reem M. Ghandour, Michael D. Kogan, Paul W. Newacheck
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Abstract

OBJECTIVE: The medical home concept encompasses the elements of pediatric care considered essential for all children. We describe here the characteristics of children with medical homes and the relationship between presence of a medical home and selected health care outcomes by using new data from the 2007 National Survey of Children's Health (NSCH).

METHODS: We used a medical home measure comprising 5 components: having a usual source of care; having a personal physician or nurse; receiving all needed referrals for specialty care; receiving help as needed in coordinating health and health-related care; and receiving family-centered care. A total of 83 448 children aged 1 to 17 years had valid data for all applicable medical home components. The NSCH is a random-digit-dial population-based telephone survey.

RESULTS: In 2007, 56.9% of US children aged 1 to 17 years received care in medical homes. Younger children were more likely to have a medical home than their older counterparts. Substantial racial/ethnic, socioeconomic, and health-related disparities were present. Children who received care in medical homes were less likely to have unmet medical and dental needs and were more likely to have annual preventive medical visits.

CONCLUSIONS: Approximately half of the children in the United States have access to all components of a pediatric medical home. Because the medical home is increasingly promoted as the standard for provision of high-quality comprehensive health care, these findings reinforce the need to continue and expand federal, state, and community efforts to ensure that all children have access to this model of care.

WHAT'S KNOWN ON THIS SUBJECT:

The medical home is recognized as a mechanism for ensuring quality health care for children with special health care needs and adults with chronic conditions. Few studies address the extent to which all children have a medical home.

WHAT THIS STUDY ADDS:

This article provides a comprehensive assessment of the proportion of children who have a medical home, the health and social correlates of having a medical home, and its impact on receipt of preventive care and unmet need.

The medical home concept encompasses the characteristics of pediatric care considered essential for all children.1,2 The American Academy of Pediatrics (AAP) developed and has championed the medical home concept for decades,3 and currently defines the medical home as a model of primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.1

The medical home has received widespread national attention as a mechanism for ensuring quality in health care for children with special health care needs (CSHCN)4,–,10 and more recently for adults with chronic conditions.11,–,13 Families, child health professionals, policy makers, and insurers endorse this model as a standard of care1,2,14,–,17 and it now serves as a centerpiece for national quality assurance measures.18 Although existing research on the pediatric population supports a positive relationship between some components of the medical home and desired child and family health-related outcomes, few studies have incorporated a medical home definition reflecting the comprehensive elements articulated by the AAP19 or studied the extent to which the medical home is available to the pediatric population as a whole.20 Furthermore, to our knowledge, none have studied the association between having a medical home and receipt of other important components of health such as dental care.

The purpose of this article was to provide an up-to-date, population-based assessment of medical home access for all children using a comprehensive definition and to describe the relationship between presence of a medical home and receipt of preventive medical and dental care, and unmet medical and dental needs. Dental care is included because existing policy guidelines and experts promote the integration of oral health services in the medical home.21,–,27

METHODS

Data Set

The 2007 National Survey of Children's Health (NSCH) is a random-digit-dial population-based telephone survey designed and directed by the Health Resources and Services Administration's Maternal and Child Health Bureau and conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics, using the State and Local Area Integrated Telephone Survey mechanism.28 Interviews were completed in 66.0% of identified households with children. A total of 91 642 interviews were conducted in households with children ages birth through 17 years between April 2007 and July 2008. The survey was administered for 1 randomly selected child in each household with an age-eligible child. The parent or guardian who knew the most about the health and health care of the selected child served as the respondent for the interview. Because many of the survey items used in this analysis encompassed a 1-year recall period, we restricted our analysis to children aged 1 to 17 years rather than 0 to 17 years.

Medical Home Measurement

The medical home measure used here was designed to approximate the components of the AAP-defined medical home concept and is the most robust, comprehensive measure used in a national survey.19,29 With the exception of the element of “continuity,” all elements of the AAP medical home measure are addressed through the NSCH medical home measure. The cross-sectional nature of the NSCH creates methodologic barriers to measuring continuity of care over time. The NSCH medical home measure is a composite of 5 components: having a usual source of care, having a personal physician or nurse, receiving all needed referrals for specialty care, receiving needed help coordinating health and health-related care, and receiving family-centered care. Each component was operationalized using ≥1 survey items. For example, the family-centered care component was measured by using 6 items: (1) whether the family reports that the child's physicians spend enough time with the child; (2) whether physicians listen carefully to family concerns; (3) whether physicians are sensitive to family values and customs; (4) whether physicians provide needed information; (5) whether physicians make the family feel like a partner in the child's care; and (6) whether interpretation services are available, if needed. If the respondent answered “usually” or “always” to each item, the child was considered to have received family-centered care. A similar process was used to operationalize the other 4 components of the medical home. The components and subcomponents of the medical home measure are included in Table 1.

View this table:
TABLE 1

Components and Subcomponents of a Medical Home: Number of Children Aged 1 to 17 Years With Valid Data

It should be noted that the components do not apply universally to all children in the sample. Specifically, the component on receiving referrals applies only to children who were reported to need referrals (n = 14 349). Similarly, the component on receiving effective care coordination applies only to children reported to need care coordination (n = 36 889) and the component on receipt of family-centered care applies only to children with at least 1 physician visit in the past year (n = 82 354). To qualify as successfully attaining the medical home, all applicable components must be met. A success rate was calculated by dividing the number of children whose providers delivered all applicable components by the total number of children with valid data. When questions on the referrals, care coordination, and family-centered care components were legitimately skipped, then the child was included in the analysis and classified as having a medical home on the basis of responses to the remaining components. Analyses excluded children with missing data. A total of 83 448 children had valid data for all applicable components of the medical home.

Outcome Variables

The impact of having a medical home was measured by using 4 variables meant to capture the spectrum of health care experiences associated with difficulty accessing medical and dental care, and timely receipt of routine preventive medical and dental care. The variables used to measure these concepts were having an unmet medical need, not receiving a preventive medical care visit, having an unmet dental need, and not receiving a preventive dental care visit.

Statistical Analysis

Presence of a medical home was computed for children according to the demographic, social, and health status variables described here. The χ2 statistic was used to test bivariate associations between each covariate and prevalence of a medical home. The independent effects of the medical home on the outcome variables were ascertained using logistic regression analyses that controlled for confounders. Confounding variables were selected on the basis of Andersen's health behavior model.30 Predisposing variables included age, gender, race/ethnicity, primary language spoken at home, mother's educational attainment, perception of neighborhood safety, region, and urban/rural residence. Need variables included perceived health status and perceived oral health (dental outcomes only). Enabling variables included household poverty status and the child's health insurance coverage status at the time of the interview.

SUDAAN software (Research Triangle Institute, Research Triangle Park, NC) was used to conduct all analyses with the weighted survey data, adjusted for the complex, multistage sample design. Unless otherwise indicated, all differences described in the text are significant at the ≤.05 level.

RESULTS

Correlates of Success in Medical Home Attainment

Table 1 lists the 5 components and 9 subcomponents of the medical home measure and the number of cases with valid data for each component among children aged 1 to 17 years. Table 2 lists the proportion of children with a medical home and each of the 5 components of the medical home. Nationally, 56.9% of children aged 1 to 17 years had a medical home in 2007. Much higher proportions of children met the individual components: 93.1% of children had a usual source of care, 92.1% had a personal physician or nurse, 81.9% of children had no problems in obtaining referrals when needed, 68.8% received effective care coordination when needed, and 66.7% of children received family-centered care.

View this table:
TABLE 2

Percentage of Children Aged 1 to 17 Years With a Medical Home and Its 5 Components Grouped According to Selected Demographic, Socioeconomic, and Health Characteristics: United States, 2007

Substantial differences in medical home attainment rates are apparent across demographic, socioeconomic, and health characteristics. Younger children were more likely to have medical homes than their older counterparts, whereas no significant differences were found for gender. There are large racial and ethnic disparities; non-Hispanic white children had the highest attainment rate, and Hispanic children had the lowest. Non-Hispanic black children fared only modestly better than Hispanic children. Prevalence of medical homes was twofold higher for children in families in which English was the primary language compared with children in families in which other languages were primarily spoken.

Where a child lives was also related to attainment of a medical home. Attainment rates were highest in the Midwest and lowest in the West. Although only a modest difference was found in attainment rates for children living in urban and rural areas, children who lived in neighborhoods considered “safe” by their parents were much more likely to have medical homes than children whose parents did not consider their neighborhood to be safe.

Strong gradients are apparent for the 2 measures of socioeconomic status in Table 2. Maternal educational attainment beyond high school conferred a twofold advantage in the likelihood of having a medical home compared with mothers with less than a high school education. Children in families with incomes at <100% of the federal poverty level were only about half as likely to meet the criteria for having a medical home as children in families with incomes at ≥400% of the federal poverty threshold. In addition, uninsured children were about half as likely as insured children to have a medical home. Finally, children who were reported to be in excellent or very good overall health, as perceived by their parents, were more than twice as likely to have medical homes as their counterparts in fair or poor health. A similar, but less steep, gradient exists for parent-reported oral health.

Recognizing that many of the demographic, socioeconomic, and health characteristics listed in Table 2 are correlated, we also examined whether the bivariate results retained their significance after multivariable analysis. Comparison of the unadjusted and adjusted odds ratios in Table 3 reveals some attenuation of effect sizes for most of the associated factors. However, the adjusted results, which show the independent effect of each covariate on the likelihood of having a medical home, remain significant with the exception of region and residential location.

View this table:
TABLE 3

Unadjusted and Adjusted Odds of Not Having a Medical Home Grouped According to Selected Demographic, Socioeconomic, and Health Characteristics for Children Aged 1 to 17 years: United States, 2007

Impact on Medical Care and Dental Care

Table 4 reveals the impact of having a medical home on access and use of medical and dental care. Unmet medical care needs were reported for 3.7% of children. A significantly greater percentage of children without a medical home (6.4%) were reported as having an unmet health care need than children with a medical home (1.6%). The adjusted analysis shows that children without a medical home had almost 4 times the odds of having unmet health care needs as children who have a medical home. Overall, 11.7% of children did not receive a preventive care visit in the past year. Children without medical homes were more likely than children with a medical home to have gone without a visit (14.0% vs 9.9%). This difference remained significant in the adjusted analysis, as shown in the lower half of the table.

View this table:
TABLE 4

Impact of Medical Home on Unmet Medical and Dental Needs and Preventive Care Among Children Aged 1 to 17 Years (N = 83 448): NSCH, 2007

The association between presence of a medical home and dental care is shown in the last 2 columns of Table 4. The prevalence of unmet dental care needs was 2.9% for all children. Those without a medical home were 3 times more likely to have unmet dental needs than those with medical homes (4.8% vs 1.5%). After adjusting for potential confounders, absence of a medical home was associated with nearly threefold higher odds of having an unmet dental care need. Overall, 17.4% of children did not have a preventive dental visit in the past year. On an unadjusted basis, children without medical homes were slightly more likely than those with medical homes to go without preventive dental care (16.6% vs 18.4%); however, this relationship reversed in the adjusted analysis.

DISCUSSION

The medical home is increasingly accepted as the standard for provision of high-quality comprehensive health care. The definition used here requires that children have not only a usual source of care and a personal physician or nurse, but also care that is family centered and provides ready access to referrals and care coordination when needed. These same principles are at the core of the AAP's definition of medical home.

Although many articles have assessed the prevalence and impact of medical homes for CSHCN,6,31,–,33 few have done so for the pediatric population as a whole. The results presented here provide the most recent, comprehensive assessment of the proportion of US children who receive their care in medical homes, the health and social correlates of having a medical home, and the impact of medical homes on receipt of preventive care and presence of unmet health needs.

We found that most children had 1 or more of the 5 medical home components but only about half of children (56.9% of children aged 1–17 years, or ∼38 million, nationally) had a medical home in 2007. Aspects of the patient-provider relationship (including access to needed referrals, care coordination, and receipt of family-centered care) remain problematic for many children. Strategies to address these bottlenecks include education and technical assistance for practice transformation, including improved care coordination, use of electronic medical records to monitor referrals and follow-up care, and shifting financial incentives to create greater parity in reimbursement of cognitive and procedure-oriented care.

Similar to findings from the 2003 NSCH,20 we found significant disparities in receipt of care in medical homes by race and ethnicity and poverty. Among racial and ethnic groups, Hispanic children fared worse, followed closely by blacks. A strong gradient across poverty categories was also documented in our study. Although these racial/ethnic and income-related disparities attenuated when confounding variables were considered, they remained significant.

Notably, our analysis also revealed large disparities in access to medical homes across health status. Children who could conceivably benefit most (those reported in fair or poor health) were only half as likely as those rated in excellent or very good health to have a medical home. Together, these health and social disparities indicate a need to target interventions toward the most vulnerable children.

There may be additional benefits to improving access to medical homes for vulnerable populations, especially minority racial and ethnic groups. An analysis of the Commonwealth Fund's 2006 Health Care Quality Survey reported that health care settings with features of a medical home (including a regular source of care, enhanced access to physicians, and timely, well-organized care) can eliminate racial and ethnic disparities in access to quality care.11 Although that study used a narrow definition of medical home and included only adults, the findings suggest that expanding access to medical homes could improve quality and increase equity among children.

Insurance provides an important tool for reducing disparities by increasing access to medical homes. Our analysis revealed that insured children were almost twice as likely to have medical homes as uninsured children. In this regard, the new health care reform law34 is particularly salient, containing several provisions that should increase access to medical homes. First, by 2014, all children will be required to have health insurance coverage. Given our finding that health insurance is highly correlated with medical home access, this provision alone should have a large impact on the proportion of children with medical homes. In addition, the new law provides for raising Medicaid reimbursement rates for primary care to current Medicare levels. That substantial boost in payment rates should increase access to primary care and, by extension, medical homes for Medicaid-enrolled children. Other health care reform provisions, including requiring private insurance plans to provide preventive care according to the Bright Futures guidelines23 at no out-of-pocket expense to enrollees, will also support the medical home movement.

Our study found strong associations between presence of a medical home and unmet health care needs. Even after adjusting for confounding variables, lacking a medical home was associated with a three- to fourfold increased risk of having an unmet need for medical or dental care. These results add to the growing body of evidence supporting the medical home as a model of comprehensive health care for children. However, although we found a small salutatory effect of medical home on receipt of preventive medical care, the association was not as strong as expected. The modest effect size suggests that medical home providers may need to use new strategies to ensure that children receive routine preventive care at recommended intervals.

Surprisingly, presence of a medical home was inversely related to receipt of preventive dental care after adjusting for other variables, albeit the effect was small and only marginally significant. This finding may reflect the significant shortage of dentists providing preventive oral health services to young children25 as well as the fact that incorporating preventive oral health care in the medical home, although recommended, is not yet a common practice for most physicians.25,–,27,35 Although the medical home may play a significant role in assuring that children receive appropriate referral and follow-up for dental problems, it does not seem to be influential in assuring receipt of recommended preventive oral health care. Parents may be unaware of professional guidelines for preventive oral health care and thus may neither seek nor expect these services from the medical home.

Compared with previous studies of CSHCN, we found similar disparity patterns in access to a medical home as well as benefits in the form of lower rates of delayed care and unmet needs associated with care in a medical home setting.6 The main difference in findings relates to the prevalence of medical homes. Perhaps because they place more demands on the health care system, CSHCN are less likely than children in general to have care that meets all of the components of the medical home.

There are limitations to this study. First, the 5 components used here to define a medical home, although designed to align with the main components of the AAP definition, are not identical; they are operational approximations.19,29 In particular, the element of continuity included in the AAP definition of medical home cannot be assessed because of the methodologic difficulties of measuring continuity of care over time in a reliable way using cross-sectional data.29 Second, the NSCH is based on parent report, which is both a limitation and strength. Although the estimates provided are limited by the knowledge and recollection of the parent, these data represent a consumer-based national measurement of the medical home concept. Third, some children are underrepresented or not represented in the survey, including those in institutional settings, homeless, or in migrant families, and those without landline telephones. Adjustments in the sample weights are made to account for these differences. Finally, because of the cross-sectional nature of the survey data set, we are limited in drawing causal inferences from the data. Many of these limitations could be addressed through thoughtfully designed longitudinal comparison studies of children receiving care in medical homes and traditional practice settings.

CONCLUSIONS

Overall, slightly more than half of US children receive their care in medical homes. Receipt of care in medical homes is shown here to be associated with reduced access problems for medical and dental care. These findings reinforce the need to continue and expand federal, state, and community efforts to ensure that all children have access to a medical home. Given the presence of socioeconomic, racial/ethnic, and health disparities in receipt of care in medical homes, targeted initiatives addressing disadvantaged segments of the child population are needed.

Footnotes

    • Accepted December 16, 2010.
  • Address correspondence to Bonnie B. Strickland, PhD, 5600 Fishers Lane, Room 18A27, Parklawn Building, Rockville, MD 20857. E-mail: bstrickland{at}hrsa.gov

  • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

  • AAP =
    American Academy of Pediatrics •
    CSHCN =
    children with special health care needs •
    NSCH =
    National Survey of Children's Health

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The Medical Home: Health Care Access and Impact for Children and Youth in the United States
Bonnie B. Strickland, Jessica R. Jones, Reem M. Ghandour, Michael D. Kogan, Paul W. Newacheck
Pediatrics Apr 2011, 127 (4) 604-611; DOI: 10.1542/peds.2009-3555
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